=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083454011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA LEO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2024
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 W CEDAR ST
-----------------------------------------------------
City | STANDISH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48658-9421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-846-4573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1549 8 MILE RD
-----------------------------------------------------
City | KAWKAWLIN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48631-8702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-215-7731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6852094069
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------